There’s yet another study out of Canada demonstrating the safety of homebirth for a subset of low risk women chosen by applying rigorous exclusion criteria. In contrast, every study of American homebirth, as well as state or national homebirth statistics that shows the US homebirth increases the risk of perinatal death.

Interpretation: Compared with planned hospital birth, planned home birth attended by midwives in a jurisdiction where home birth is well-integrated into the health care system was not associated with a difference in serious adverse neonatal outcomes but was associated with fewer intrapartum interventions.

The results reflect the many restrictions placed on homebirth in Canada.

1. Canadian midwives have far more education and training than American homebirth midwives. Canadian midwives must have a university level midwifery degree and extensive in hospital and out of hospital training. American homebirth midwives, in contrast, are really just lay people who awarded themselves a bogus credential that can be obtained with a period of unmonitored study and apprenticeship. American homebirth midwives have such ludicrously low standards that they had to “strengthen” them in September 2012 to mandate a high school diploma.

2. There are strict risk criteria for homebirth eligibility. Women with breech, twins, medical complications of pregnancy, pre-existing medical conditions and more than one previous C-section are not eligible for homebirth in Canada. Therefore, homebirth takes place within a well regulated medical system, not outside it and not in opposition to it.

3. Transfer rates are high. More than 45% of first time mothers were transferred to the hospital for an overall transfer rate of 24%. Transfer is undertaken if complications might occur. The threshold for transfer is remarkably low in contrast to American homebirth where the threshold for transfer is dangerously high, often not occurring until complications happen.

4. Homebirth is integrated into the medical system because Canadian midwives are integrated into (and regulated by) the medical system. American homebirth midwives are a second, substandard class of midwives that exist because they couldn’t or wouldn’t meet the standards of the medical system.

5. Childbirth is recognized as inherently dangerous. This is the key point. No one trusts birth; everything is predicated on the assumption that birth is untrustworthy. Safety is ensured NOT by managing complications at home, but by making sure that complications do not happen far from expert medical assistance of obstetricians and pediatricians. Nearly everyone who is at higher risk for complications is excluded a priori. Care during labor involves prompt transfer of anyone who might develop a complication. Strict education and training standards ensure that midwives have the experience to recognize impending complications instead of waiting for them to occur. Integration within the healthcare system means that there is no financial incentive for Canadian homebirth midwives to keep women at home as opposed to transferring them to the hospital.

What would we need to do if we wanted American homebirth to be as safe as Canadian homebirth? It’s pretty simple:

Abolish the CPM and restrict midwifery to people with university level midwifery degrees.

Enforce strict eligibility criteria for homebirth.

Exclude from homebirth anyone at increased risk of complications.

Transfer at the first sign of potential problems.

Require homebirth midwives to have hospital privileges.

Canadian midwives have shown that homebirth can be safe IF complications are expected and patients are transferred before complications occur. It has also demonstrated why American homebirth will NEVER be safe as long as we allow poorly educated, poorly trained lay people to award themselves counterfeit midwifery credentials and use those credentials prey on American mothers and babies.

I had a homebirth in Ontario, but when I wanted another one, my midwife said no because I tested positive for the group B strep bacteria … and I was transferred to OB care (although she still stayed on as my birth coach, since my husband had passed). It was a good thing too because I had a cord prolapse and needed an emergency c section! Baby was perfectly healthy in both cases, FYI.

guest

That’s what we ought be doing in the US.

LindaRosaRN

Colorado has just published its DEM data for 2013 and 2014 — in ridiculous graphs again (see link). These practitioners will be having their sunset review in the 2016 legislative session, i.e. soon. They want suturing, ultrasound, etc. privileges, and they don’t want the data collection to continue.

I am actually trying to extract some meaningful data from those deliberately misleading pie charts of theirs.

For 2014 – first of all we would need to know how many licensed midwives practiced that year because it appears that not all of them filed the reports. Secondly, we would need to know total number of births attended by DEMs in Colorado – last publicly available figure was the one dr Tuteur obtained for 2010 and it was 914 births and 15 perinatal deaths at an inexcusable 16.4 / 1000 perinatal mortality rate.

The data suggests that there were 802 births attended at home and 120 transfers during the labour, which totals at 922 planned OOH births in Colorado for year 2014 and the total number of deaths they admit to in this deliberately misleading report is 10.

Linda Rosa

These graphs make it very hard to interpret the data, which was no doubt the idea.

In 2014 there were 56 DEMs renewing according to the Statistical Summary, but according the sunset review there were 54 DEMs renewal and 7 new DEMs signed up (new DEMs don’t need to answer questions about the past year’s practice).

I get 802 planned births. Does this figure include transfers during labor? I presume so.

The 2015 Sunset Review claims the “total number of births performed” for 2014 is 771. I don’t see how they got that number in any way or fashion.

There are a number of other discrepancies between the figures in the 2015 Sunset Review and the 2014 Statistical Summary, and I have asked DORA for clarification. DORA has also omitted the number of newborns transferred the first 24 hours.

==============

Neither DORA nor the DEMs have had an issue with Dr. Tuteur’s calculations, so perhaps we should get her guidance.

In the past, the DEMs have tried to excuse the high PNMR by claiming that when two or more DEMs attended the same demise, multiples of the same death were recorded. However, DORA is compelled by law to collect the cause of death and circumstances around each death, so duplicates should be very easy to identify. (Note that cause of death and circumstances — required by law — are also missing from the statistical summaries.)

yugaya

Thank you so much for your comment, I was going insane over this.

I got the number of births from 56 respondents with 14.32 average = 802. That would be the number of births attended without the transfers.

There should be no overlapping because there is only one reporting midwife for each birth attended. The discrepancy between 771 total in 2015 Sunset review and their 2014 statistical report number of 802 could be the births attended by the two missing midwives ( 54 in Sunset vs 56 in their 2014 summary).

I got 10 total losses because 12a) is 1. ( 2% of 56 midwives reporting 1 loss) = 10 deaths in 771 or 802 births with DEMs in Colorado in year 2014

. So it’s either 13/1000 or 12.5 /1000 perinatal mortality rate which is insane, and only slightly better than the last data we have obtained thanks to dr Tuteur which was 16.4/1000 in Colorado for the year 2010 and out of hospital birth with a DEM.

Linda Rosa

Look again at 12a: one person is reporting 2 deaths. (Look at the little green box; green now stands for two instead of one.)

I believe the presentation of this data has been sloppy as well as deliberately misleading.

yugaya

You are right, and I do believe the data is presented deliberately like this.

So that brings the total to 11 deaths in 771/802 births, and the death rate up to 14/1000.

Linda Rosa

As soon as I hear back from DORA about clarifications, I will work on a spread sheet, which I hope several people will check for accuracy.

yugaya

Young CC Prof who is a regular on this blog is a statistics professor, and there are a couple more regulars who teach science subjects at university level. I am sure they will be more than willing to help. I was just trying to get the more recent numbers for Colorado because someone mentioned that they are being deliberately hidden from the public since 2009.

Canadian home birth is not better than UK home birth – there’s a heaping helping of ideology still at work.

omdg

Was this an intention to treat (as randomized) analysis?

fiftyfifty1

These women were not randomized at all. The women themselves chose the intended place of delivery.

omdg

On nm, I see it is observational.

omdg

Still, wondering whether those who got transferred to hospital analyzed as homebirth.

Name

As far as I can see, they were analyzed as homebirth.

Jpow

While some provinces have licensed midwives and regulatory bodies, others do not. I live in New Brunswick and we have no regulations regarding midwifery and no certifying body. What we do have, however, is an underground network of women who call themselves “birth attendants” and who’s only knowledge of child birth is having given birth themselves. They actively seek out pregnant women and encourage them to birth at home with an attendant, or completely unassisted. They are also actively campaigning AGAINST regulation of midwifery in NB, as this would put them out of business. They hold their own “village prenatals” where previous home birth moms push others to birth at home. They discourage any and all medical care during pregnancy, birth and early childhood. They are some of the most charismatic and dangerous women I have ever met. It’s just sheer luck that there have been no deaths or complications (that I am aware of)!

Brooke

So an integrated system in which midwives and doctors are not competing for patients actually works? Yeah I’m shocked.

Amy Tuteur, MD

No, a system in which midwives are bound by strict regulation works. When midwives trust birth, babies die.

GTA

In Toronto, there are more people looking for midwives than there are midwives available. To get a midwife, you have to call as soon as you get a positive pregnancy test. That might just be the result of having them integrated into the system.

Amy Tuteur, MD

Doctors don’t have to compete for patients. There are more than enough. It’s midwives who have to compete for patients and it’s their efforts to make money that lead them to let babies die.

Azuran

Then I guess you agree that the CPM credential should be banned. All midwives should be CNM. All of them should be affiliated to hospitals, have transfer priviledge, and work under strick practice guidelines with oversight from OBs and other medical professional.
This system works because the midwives are trainned medical professional following medical standard.

yugaya

Actually it doesn’t because clearly the ideology of natural childbirth at all costs has creeped its way into Canadian midwifery too. Read the testimonies of women on this thread and the cases posted and you might begin to understand why. This study is meaningless due to the fact that any and all complications were removed. It only proves as Azuran down in the comments perfectly pointed out:

” In women who gave birth without any complication, home birth is as safe as hospital birth.”

Bombshellrisa

A uniform system of education, training, and a title that is reserved only for professionals who have completed that goes a long way. If women want to attend births without completing the necessary education, they have to call themselves non medical professionals (traditional birth attendants) and keep their support “from the waist up” (a quote from the RCM in British Columbia)

Maya Markova

“Women with… more than one previous C-section are
not eligible for homebirth in Canada” – shouldn’t women with one C-section also be considered not eligible? Isn’t the risk of VBAC without the option for emergency C-section too great?

Daleth

Well, not unless you consider a 1/200 risk that your BABY WILL DIE to be too great… um.

Women with one cesarean are eligible for HBAC in BC – meanwhile many women wanting MRCS are still facing unreasonable barriers.

Freddie

The issue is not to make home birth “as safe” in the US as in Canada. The issue is to make it safer than hospitals. Will never happen. CPM versus CNM? No significant differences in outcomes. The problem in home births, as Amy has pointed out many times, is that it’s too far from hospitals/interventions and personnel is inadequate to care for emergencies. That’s not being helped much by CNM versus CPM, as bad as CPMs are.

yugaya

It only happens in studies like this one – after you remove a couple of hundred dead babies from the equation and look at the resulting data from the right angle.

Gatita

Another major problem is failing to risk out and transfer when warning signs pop up. Homebirth might be a reasonably safe option except when ideology is driving the decision making.

GTA

In Ontario, Midwives aren’t CNM’s or CPM’s. Nurses refused to bring them into the fold way back when. Midwives become regulated in 1994 in Ontario and they have to do a 4 year health sciences degree in midwifery at university level. Many of them were nurses, but they are separated professions.
As far as being too far from hospital personnel, it takes 20 minutes to prep an OR and my backyard backs onto the hospital. I haven’t seen midwives in Ontario offering homebirths where they were more than 20 minutes from the hospital. It’s pretty much something offered in large towns and cities. Otherwise it’s just hospital births.
I suspect you underestimate how many types of medical crisis midwives are trained to handle in some places. However, the primary goal is to sniff out problems long before labour. Anything that popped up that could be problematic, my midwife followed up on.
Why safer than hospitals? I understand requiring them to be as safe as hospitals, but not safer.

Sue

I’ve been wondering how the Canadian system treats first-times, considering that nulliparous women had 3x excess neonatal mortality in the UK Birthplace Study. In this paper, the planned HB group had a number of first-timers, but only about half of them ended up delivering at home.

INterestingly, there wasn’t much difference in vaginal birth rate (90.9 vs 87%). So, staying at home got you less pain relief and a relatively high chance of an emergency transfer.

The Bofa on the Sofa

That last statement is what needs to be made more known. A hospital birth has only a 5% lower chance of a vaginal birth.

Roadstergal

The thing I always wonder – hearing all of the horror stories below, and the UK midwife scandals, the comparison to hospital birth is a comparison against already-substandard care. Would hospital birth without the worship of ‘natural’ make homebirth look even more dangerous? Would the mortality rate at home be 5x, or more?

I think the Dutch comparison between midwife-lead birth in any setting vs OB-lead birth was very telling, in that context.

Puffin

I delivered with midwives in Ontario nine years ago and have permanent damage to myself, and possibly my son, because of it.

For one, as soon as I requested an epidural during labour, my midwife ignored me afterward (second midwife didn’t make it to the hospital until after delivery. My labour was nine hours…) They missed that a piece of placenta wasn’t passed. It continued to bleed heavily during my postpartum period and when I complained of constant bleeding, including passing clots the size of large grapefruit as long as a week postpartum and prolonged painful cramping with gushes of blood for weeks, they told me it was normal. I was still bleeding very heavily at my discharge (6week pp) appointment and it was only then that they told me I should see a doctor if it lasted another week.

At 7w postpartum, it was discovered I still had several inches of placenta left in me which was still bleeding. I’d spiked a fever by then. I had a D&C – I was told it was very firmly adhered and I may have had mild accreta – and was put on antibiotics. I consider it very lucky that I didn’t develop a severe infection since I had a piece of placenta in my uterus over a month and a half postpartum. I still ended up quite ill.

Plus there’s the tears they didn’t repair that they said didn’t require repairs. Yeah, they did. They absolutely did and once I’m done having children I’ll be seeing about surgery to repair my mangled labia.

More importantly than that, my son was severely jaundiced. Yes, normal but he turned yellow within 24h of birth which I now know is a very bad thing. We were sent home only 4h postpartum so this wasn’t evaluated in hospital. I have photos proving the timeline, but his neonatal observation notes say otherwise. The midwives told me to put him in front of the window naked. In a draughty flat. In Canada. In January. This, of course, does not treat hyperbilirubinaemia. He SHOULD have had his bili level checked and been given phototherapy at minimum. My second child (I had OBs that time around) had jaundice which wasn’t even nearly as bad as my son’s and she almost needed a transfusion because her bili was so high, so I can only imagine how high my son’s bilirubin level must have been. I know that the severity of the jaundice and the bilirubin level are not perfectly correlated, but still… my kid was as yellow as someone with end stage liver disease and the midwives told me it was normal and he didn’t need a blood test. He has developmental delays now and I really can’t help but wonder if it might be subtle kernicterus because he went for a month and a half with untreated hyperbilirubinaemia.

I’m a medical student now and I know how important accurate charting is. I read my notes from the midwives and can spot areas where they completely glossed over the truth or fabricated things out of whole cloth and I am angry because I didn’t know enough at the time to challenge them. I haemorrhaged, but they didn’t even tell me. It’s recorded in my notes, but they never once told me. And they sent me home four hours postpartum… after I haemorrhaged!

I will never deliver with midwives again. I’m most likely going to be a family physician in a rural area and I’m rather glad the place I’ll practice doesn’t have midwives because I have such a terrible taste in my mouth after what they did to me that I’m hesitant to trust the profession.

Medwife

That is outrageous negligence. I’m sorry you received such terrible treatment and I don’t blame you a bit for not trusting midwives. It’s not how I practice but when that’s your only experience, how could you feel otherwise?

Puffin

I think I’d need to get to know a midwife very well on a professional level before I’d be comfortable working with them if midwives ever do make it out to where I’m from. The city I am training in does have a fairly high number of midwives so I know I will interact with them (hasn’t happened yet, but will before long) during my training, and I am just hoping that the ones I run into are nothing like the ones who treated me. I’m certainly open to having my opinions changed by meeting better examples of the profession.

Guestll

Here in Ontario, I delivered with midwives 4 years ago. I was 40 years old, first-time mother with a terrible OB l history (multiple miscarriages, one in the 2nd tri) and a documented small pelvis. My baby was conceived via ART.

I was strongly encouraged to homebirth by my primary midwife, despite telling her numerous times that my husband (who lost his birth mother during childbirth) was strongly opposed to homebirth. Primary midwife even called my husband at work, absent my knowledge, to encourage him to come to a session at the clinic on homebirth.

During the pregnancy, when I asked about GDM testing, my primary midwife said, “If you have gestational diabetes, I will eat broken glass” (BMI of 19 pre-pregnancy). That’s what constituted “informed consent” and I was never tested for GDM.

Baby was breech until about 36 weeks. Primary midwife told me I would have a version, and that vaginal breech “is not really that big of a deal.” I declined a version and stated that I would have a section if baby did not turn (baby did.)

Primary midwife did not stop the pressure for homebirth, felt I was an “excellent” candidate. Told my husband “you live right around the corner from the paramedics.” My husband walked over there and asked one of them about their experience in delivering babies in emergencies. Needless to say, the para’s response did nothing to alleviate my husband’s concerns.

My husband finally agreed reluctantly to a homebirth. Baby was estimated to be between 6 and 7 lbs via Leopold’s at 40w5d. I walked around for over a week dilated to 5 cms/100% effaced. At 41w, I began to suffer from blurry vision and felt unwell. BP, which had always been in the range of 110/55, was up to 140/90, and I was on the “borderline” of spilling protein. Primary midwife said I did not have pre-e and she was not concerned and that homebirth could proceed as planned.

At 41w3d, I was given a BPP – EFW of 9 lbs. I was told that the baby was posterior. Primary midwife said, “that’s no big deal, most of them turn, and if that doesn’t happen, it’s still not a big deal.” The following day, another BPP. EFW of 9 lbs 3 ozs. After watching my little one in profile on the screen, practicing breathing, I begged for an induction. It was declined on the basis of “no rooms.”

At 41w5d the senior RM intervened and explained the risks of postdates. She obtained a bed for me, I was induced via ARM only, and delivered 9 hours later of a posterior, 8 and a half pound baby. I pushed for 2 hours and 36 minutes on a failed epidural. No one offered a pudendal block, or gas, or anything other than sterile water injections, which did not work and felt like 4 bee stings in the back at the height of a contraction — and I still vividly remember the feeling of being torn apart at the hips, over and over and over again. Baby got stuck at the end and was manually extracted by the midwife. Pain on top of pain.

That’s my experience of Canadian midwifery. Never again.

yugaya

I am so sorry you were mistreated like that. And your story just reinforces my conviction that the only thing that is safe in Ontario homebirths is the midwives from ever being prosecuted or held accountable.

Guestll

In fairness, I have known some very competent RMs and have friends who’ve had safe and healthy births with RMs, both in and out of hospital. But the woo is quite prevalent and it poisons what should theoretically be a good system.

Friend #1 – delivered first baby at home at 42+3. Baby had MAS, transferred to NICU.

Friend #2 – delivered first baby at home at term and pushed against an incomplete cervix before transferring. Major cervical lacs and bleeding.

Postdates homebirth and the inability to accurately assess dilation/effacement speak to a culture more concerned about the experience than overall safety. I also think FTMs should be risked out, period. Proven pelvis only, no postdates, and no AMA.

demodocus

Jesus. Sounds pretty traumatic to me. How’re you and the baby doing?

Guestll

Great. Surprisingly, I was able to walk very shortly after the delivery, despite a large 2nd degree tear. Recovery was quick. I have urinary incontinence when I cough/laugh, though.

Baby was long, skinny, long nails, dry skin, almost no vernix, and the placenta was calcifying in spots. Classic signs of postdates. Very bruised around the face, but fine and well in the end.

Guestll

I just want to say here, publicly, thank you to Dr. Amy for the wise counsel she’s given me over the years with respect to both my baby’s birth and recently, to the urinary incontinence. I obtained a referral to a urogyn and it’s making a difference. Thank you, Amy.

Megan

That sounds atrocious. I’m so sorry your wishes weren’t honored throughout your entire pregnancy. Glad you and baby made it through.

Guestll

Primary midwife was extremely charismatic. I now understand why some women get so attached to their midwives. In hindsight, I think she may actually be a first class narcissist. It became clear to me in hindsight that this was all about her. The first thing she said to me when she visited me the week after I delivered (she did not deliver my daughter as she was not on delivery call) — “Hi! Sorry you didn’t get your homebirth.” Nothing about the wee baby in the wrap, right under her nose.

The Bofa on the Sofa

As I have said, successful con artists have to be slick and charismatic. If you don’t have the goods, you gotta sell something

Sue

What IS it with these sterile water injections? A form of acupuncture?

Guestll

Primary midwife said they were awesomesauce. Worse than useless, and really, what’s more fun than being stung in the back at the height of a contraction during transition?

Medwife

I was taught that they were legit pain relief. Seeing it done quickly disabused me of that idea. It’s like punching someone in the eye after they stub their toe and pointing out that they’re not thinking about their toe anymore. Ugh, the screams echoed down the hall…

Azuran

Well…..technically, it could somewhat work XD. For example, applying pressure around a wound does somewhat lower the pain from the wound itself. But just because it has some effect doesn’t make it an acceptable form of analgesia.

DirtyOldTown

What is it with sterile water injections? Glad you asked Sue. You see, unlike Evil Medical Interventions (TM), which require specialized knowledge and regulation, sterile water injections can be administered by anyone, even your house cleaner! It’s the democratization of pain relief. Aren’t you glad we live in an egalitarian, classless society? Now hold still while I adjust your aura.

CanDoc

Yes. As an OB, this is consistent with some of what I’ve seen. But your chart undoubtedly clearly documented “patient offered options: decided home birth if feasible, declined, diabetes screening, considering vaginal breech delivery.” All based on inaccurate or inappropriate counseling. Because midwifery can be just another form of paternalism cloaked in a dangerous language of “choice”.

Guestll

I have my chart, and you are not wrong.

Guestll

Other things in my chart — to the effect of “client says NVP improving, weaning off Diclectin” — that is a baldfaced lie. Primary RM didn’t like Diclectin and repeatedly suggested that I shouldn’t take it and should try alternative methods of controlling the vomiting. I explained to her that both my mother and sister had HG, my sister to the point of PICC/TPN, and she said, “that doesn’t have anything to do with you, though.” I saw an MFM for CVS at 12 weeks and actually threw up in the geneticist’s office. I was offered Zofran for the very first time. That’s not in my chart, either.

Medwife

She didn’t like B6 and doxylamine succinate? That’s already next to nothing.

Guestll

She didn’t, and she didn’t prescribe it to me. It was prescribed by my RE, because I started barfing even before the home test turned +. I ended up on quite a heavy dose of Diclectin + Gravol suppositories before Zofran became my friend.

Primary RM suggested acupressure and a few other things, none of which alleviated the constant nausea and vomiting 3-4 times per day.

Medwife

Such bullshit.

fiftyfifty1

Wow. A 40 yo was not offered induction until 41+5? Holy smokes! If Ontario midwives are making decisions like that it is no surprise that their hospital mortality rates are no better than their home rates.

Guestll

Not only was I not offered an induction until 41+5, I would have not been offered an induction at all had the senior RM not intervened. I had 3 or 4 (can’t remember) membrane sweeps between 39 and 41 weeks which did jack, but was repeatedly told, “looks like any day now!” I have since learned about OP babies and how OP positions can delay the onset of labour.

Madtowngirl

Why do home birth advocates insist that vaginal breech is “not a big deal?” Breech babies are a huge deal! A lady in my pregnancy group delivered a breech baby vaginally, and that child now has CP.

I’m sorry that your experience was so awful. The way you were treated is shameful.

So if a baby died because of a placental abruption during a home birth, that death just didn’t count? What now?

Azuran

I do get the point that hopsital births have a lot of higher risk patient (that are not supposed to be allowed home birth in canada) so you want to compare population of similar risk women.
But once you have those population, any and all complications/death that appeared after the labour started should be included.

mostlyclueless

Yeah. Of course you want to exclude women for risk factors that either did or should risk them out of home birth — but if you also exclude women who had an unforeseen complication after labor begins that could only be managed in the hospital, of course you’ll stop seeing a benefit of being in the hospital.

It’s like saying there’s no benefit of going to the hospital if you have heart disease — once you exclude all the people who have heart attacks.

Azuran

Conclusion: In women who gave birth without any complication, home birth is as safe as hospital birth.

Amy Tuteur, MD

Right. The take home message is, “Never trust birth!”

Roadstergal

Among drivers who do not crash, comparable outcome are observed in those wearing seatbelts and those driving unbelted.

Medwife

I agree. If there is a death related to peripartum eclampsia, by what logic does that not “count”?

mostlyclueless

Can that cause infant death or only maternal? I note that there were no instances of maternal death in either group.

Medwife

Both.

mostlyclueless

Although actually if they just removed every possible cause of maternal death then maybe that’s not surprising.

OttawaAlison

I’m hoping I was in the hospital comparison group for that study! I had a good outcome (healthy baby) at an Ontario hospital in 2006 and was low-risk. That said, I am sure they could say the fact that I had an epidural, was induced and finally had a csection as negative? But 9.5 years later it wasn’t in the least. I got my daughter!

CanDoc

As a Canadian OB I can attest that what is said reassuringly on paper and what happens in real life can be very different things. I sometimes worry that we have MWs who are well trained enough to document defensively even though they counsel inexcusably. (Eg, Pt is told, “Home VBAC is common and supported, just as safe as hospital birth with just one prior CS”, and then chart says, “Patient offered hospital VBAC, risks carefully reviewed including maternal/fetal risks, patient wants home delivery.” Have seen/heard it enough times to know that this is selective/directive counselling and documentation happening, since I haven’t seen it to nearly the same degree in patients followed by GP-Obs or other OBs. Glad to not be working with MWs in my current position. Although often satisfying, it was at times utterly terrifying.

yugaya

“MWs who are well trained enough to document defensively even though they counsel inexcusably.”

Is there any chance of an outside, independent review of the outcomes any time soon?

CanDoc

I suspect never. And, to be fair, most of my MW colleagues are excellent, careful, and prudent… and a pleasure to collaborate with. But the woo woo ideology permeates. Remember, many of these women worship Gaskin and Simkin as much as their American counterparts.

yugaya

Ontario has a superb-looking BORN database. Hopefully in near future we will see either their or an independent third party review of the real perinatal mortality for homebirths in Ontario.

theadequatemother

My experiences with Canadian midwives have been largely negative. Although perhaps that’s because as an anesthesiologist I’m the enemy.

ON midwife

I’m not sure why I would consider an anesthesiologist an enemy 🙂 epidurals are excellent…some women prefer to suffer but such is their choice..

ON midwife

Yes it’s true, unfortunately. I have been posting here since 2011 (the year I started my clinical training) as the means of venting frustration with the woo woo. I’m now practicing in Ontario and I have to say that many Canadian-trained midwives are into Gaskin and the gang as well as things like homeopathy and other same BS. The ones who come from overseas (Iran, UK) are more sensible in this regard and are not into the fluff. Overall, lots of good potential in the profession I think but we need more rigorous scientific training and standards.

Dr Kitty

Actually, what you need is a court case.
Because, despite what you document, juries and judges believe the testimony of patients. After all, they only go through this once, healthcare professionals do this thousands of times. Patients usually remember it better.,

In order to have a court case there would have to be an outside involvement, which is unlikely to happen when their own oversight body sees nothing wrong with the actions of the midwives in these cases.

Guesty

I would love to see the U.S. adopt the Canadian midwife system because I think women have the right to choose home birth. That said, I will never understand why anyone would.

When my first was born, I took a car seat installation class. I practiced getting the seat in and out until I knew I had it right. I did that for three kids, twelve years and god-knows-how-many seats straps checked, every ride, every time. My kids are all out of car seats now and we never once needed one because we were never in an accident. Oh, the money! The hours! The sobbing, confined babies!

I would never not properly install a car seat and I would never choose to birth without a doctor in a hospital.

Dr Kitty

I am going to say that hands down the single best baby gadget we bought was the isofix base for my rear facing infant car seat.
The base clamps into the car and then the seat snaps in and out in seconds. Not only is it convenient, but I never have to worry if I have fitted it just right.

Medwife

The best baby paraphernalia I DIDN’T get with #2 is an infant carseat. I went with a convertible, so it’s not a carrier but has various settings to make it usable from newborn to 60 lbs. I had an infant seat for #1 and getting it in/out of the car and carrying it put me in physical therapy and a wrist brace. I’m “wearing the baby” this time around, which is nice for when I’m trying to keep #1 from bolting into tragic.

Kelly

I have to say that I love the car seat that snaps in and out and use it all the time. I use carriers as well and just bought the Ergo in order to put my middle child on my back. I have a Bjorn that I used when the babies are smaller but I have to say that it is not as easy to manage the other child or get any work done around the house when they are in the front. I can do it but it just too awkward and if I bend over, I feel like they are falling out no matter how tight they are. I have never heard of anyone having medical problems with the car seat but I think that it is something that people would have to take into consideration when deciding on what works best.

Medwife

I don’t know if it’s common, but I had to twist and lift at a non-eronomic angle to get it in/out of the car, and then carrying it killed my shoulder. I had a superchunk baby, so maybe that was the issue 🙂 I hear you about the disconcerting falling out feeling. I’ve been working my squatting muscles!

Kelly

They get heavy very quickly. I know I had bruises on my leg from hitting it with the carrier.

Mishimoo

Thanks for reminding me to pin the new carseat I was thinking of buying for our toddler soon. He’s nearly too tall for a normal one but he’s not old enough for a booster seat, and I keep forgetting to find it when I’m online.

Liz Leyden

The best baby gadget I got was a double stroller base for the car seats. I could strap both car seats into it, and quite a few groceries fit in the bottom. I also got a single model for the rare times I had only 1 baby with me.

StephanieA

Even if I lived in a country with ‘safer’ home birth statistics, I still wouldn’t feel comfortable having a home birth because 1, low risk can become high risk at any point during labor, and 2, I love epidurals.

denise

I am from Montreal, QC. Only a small percentage of deliveries are done by a midwife (despite the high demand, we do not have many midwives in the province). What we do have is GPs that specialize in obstetrics. They follow low to medium risk patients (you can still choose to be followed by an OB even if you are low risk). I gave birth at the Lasalle Hospital, known as doulas’ favorite hospital (I didn’t care for that, it was the closest hospital to my home. In hindsight, I should have stayed away). I had a normal pregnancy, yet had complications because of the cord. The baby’s heartbeat kept dipping after each contraction. Lasalle made GPs deliver normal pregnancies (based on my understanding each hospital is different). The GP called the OB. He was in a C-section. Instead of calling the second OB on duty, she made me wait forty five minutes. When the OB arrived, he gave me three contractions to get the baby out (he said a c-section at that point might have taken at least as long and the baby needed to be out). My daughter’s first UPGAR was ONE. Thankfully she recovered fast and is healthy. If I have more kids, only an OB will touch me. I am not taking the GP route, let alone a midwife.

Madtowngirl

My local news ran a story on this study thus morning. Of course, they made no mention of the fact that Canadian midwives are required to get university training, unlike CPMs. The irresponsible scientific reporting makes me angry.

fiftyfifty1

I am very concerned about the paper’s Figure 1, the flowsheet of how they selected and excluded cases for the study. It says that 189 deaths were excluded from the homebirth group because of “fetal demise before labour or unknown timing of fetal death”. They excluded an additional 18 homebirth cases because of “missing significant data including perinatal and infant death”. The similar size hospital group, in contrast, excluded ZERO such cases of fetal death. How is this a fair comparison?! Sure, homebirth is just as safe, as long as we throw out around 200 dead babies from the homebirth group. Who would find this reassuring?

MaineJen

And aren’t they throwing those cases out, essentially, because of poor record keeping? I can see how you wouldn’t have a time of death for a demise before labor, but if it happened during labor, the midwife should at least have a ballpark. They are supposed to be doing intermittent monitoring. Right??

yugaya

Many of the cases were never even counted because the *planned* location of birth was not home – like that one woman I posted about who was extremely high risk but was receiving poor homebirth care instead of being sent straight to the hospital.

Anecdata from the birth stories found around the internet suggests that a high risk patient who wants a homebirth in Ontario will often preregister for a hospital birth to cover the midwife and then have the baby at home “accidentally”.

Trixie

Do you have that chart from the 2009 study?
And yeah, anecdata from the Internet, there’s a lady in a crazy HBAC group who had an HBAC in Ontario with a history of placenta accreta and precipitous labor. Her midwives were apparently all for it.

yugaya

THAT crazy lady was preregistered for a hospital birth and then *accidentally* had a HBAC with THREE Ontario midwives in attendance, all three supposedly living less than 10 minutes away from her, while she herself was at least an hour from the nearest hospital.

A snippet of her high risk history:

– I have a history of very fast births (two precipitous, one self-induced hospital VBAC with castor oil)

-I had a PPH, postpartum hemmorage ( twice),

– 3 hour surgery, almost a hysterectomy (accreta)

– . I had a miscarriage between my third and my fourth and had a D&C

– 2 manual removals/deliveries of the placenta

-I had an extended tear, my incision on the inside of my uterus was extended (on the inside)

-. 2/3 pregnancies had went over 41w

I last saw her telling me how I should ” check out the college of midwives website and you will see that they only accept care for low risk women”. :)))

MaineJen

WTF

Haelmoon

Just like the case I have heard of: twins (breech-breech) at home with four midwives. That is not low risk at all, how can we work collaboratively, when there are members in the midwifery college who think this was a good outcome?

yugaya

She claims that the third midwife was present because she was at high risk of PPH. Since the birth was not planned as homebirth ( wink wink nudge nudge), and she was preregistered into hospital/OB care, it is not even plausible that instead of EMS a third midwife was dispatched for a precipitous labour and birth that is not supposed to happen at home at all.

Local sources close to the crazy lady say that the third midwife present at her insanely high risk HBAC was an illegal birth attendant. Which makes it even worse.

SporkParade

Yeah, CPMs who move to Israel do something similar. Basically, they find someone crazy enough to still attempt a homebirth after being risked out, and then they tell the patient to register the birth as being either an accidental homebirth or an unattended birth with a “doula.”

Cody

Actually, all home birth candidates in Ontario have to register for a hospital birth. This is in case of transfer, but also because a mother can choose to go to the hospital for the birth at any point in time.

yugaya

The issue is not with a planned, approved low risk homebirth women registering with hospital as back up – we are talking about homebirths where woman and midwife pretend that the birth is planned to take place in the hospital and then when it occurs at home claim how it was unplanned. What these midwives ae failing to do is to document going against medical advice and failing to disclose risks accurately while actively encouraging the women to do it.

tariqata

I agree that the missing information about perinatal and infant death is concerning in and of itself, but it’s not clear to me from the paper that all of those cases, or the 189 cases of fetal death, were planned home births. My reading of figure 1 is that those cases were excluded before the dataset containing all midwife-attended births for 2006-2009 was sorted by planned place of birth, so they could have been either hospital or home. Did I miss something in the text?

fiftyfifty1

“it’s not clear to me from the paper that all of those cases, or the 189 cases of fetal death, were planned home births.”

Ah, you are exactly right. They took them out of the data set that included ALL women planning to deliver with a midwife (no matter place of birth). My error.

That said, as you indicate, this missing info is concerning. Perhaps they were evenly distributed between planned home and planned hospital, perhaps not. I wonder why they decided to exclude them without giving us that info. It works out to roughly 1 out of every 3,000 pregnancies that ends in death…but excluded from the study and no more info for us.

yugaya

And one of the most horrific cases of unethical conduct I have ever seen

2009-S-9. High risk mother and horror high risk home stillbirth at almost 42 weeks in October 2006.

“The midwife engaged in an argument with the EMS crews about where to transfer the patient and child. There was significant discussion about seeking authority to cease resuscitative efforts on the baby once it was learned how long the infant had actually been without signs of life. The midwife was demanding that the ambulance transfer the patients to Hospital A, while the EMS crews were being directed by a doctor to transport the patients to Hospital B. The EMS crew was given permission to cease resuscitation efforts on the infant and the mother and stillborn were transported to Hospital B at 1230 hours.

.In this case, contrary to the guideline, the mother was advised to drink juice, lie down and call back if no movement was detected. The first midwife had many opportunities and clinical reasons to call an ambulance (e.g. no foetal heart detected, no second midwife at birth, baby not responsive at birth and inability to set up bag and mask for neonatal resuscitation). The second midwife also chose not to call an ambulance immediately upon her arrival at the scene 30 minutes after the birth. She waited another 30 minutes (now one hour after actual birth), to call the EMS

The resuscitation performed by the attending midwife appears to be totally
inadequate. The record indicates that the midwife unwrapped the nuchal
cord that was void of blood. She then suctioned, although there was no
notation of how the suctioning was done. The record indicates that the midwife did one minute of cardiac compressions, then“quit”. The midwife was obligated to perform neonatal resuscitation until the EMS arrived to assist and transport to a hospital. The midwife was certified to provide neonatal resuscitation and did not in any way offer the accepted resuscitative efforts for which she was trained.

There was no notation on the record of the parents ever asking the midwife to cease attempts at resuscitation. Upon arrival of the EMS crews one hour after the birth, the parents gave permission for resuscitative
efforts to be performed. The midwife did not communicate with the EMS
that the infant had been deceased for almost an hour. ”

And keep in mind that no disciplinary hearing was held even over this death or any other case that is documented in the coroner reports between 2004-2011. So excuse me if I don’t think that this new study proves anything other than the lengths to which homebirth apologists will go in order to keep these deaths deliberately hidden. Or “excluded”, as they prefer it.

Allie P

That’s horrific. The EMS weren’t told the baby had been dead at least an hour?

yugaya

Yes. And when they were told that the baby had been dead for an hour before they arrived and they discontinued the resuscitation, the midwife argued with them wanting to transport the mom and the dead baby to a specific hospital.

I can’t even begin to imagine the trauma of the parents.

yugaya

2009-N-12 – records “unclear” for a planned homebirth (must be “coding
errors”), one GBS culture got “lost”, so second one was ordered without
any explanation:

“GBS culture on August 18 at 36 weeks was not reported. The GBS culture repeated on August 28 2008 at 37 weeks 4 days was negative. A home birth with midwives was planned…Post mortem examination revealed severe diffuse acute bronchopneumonia in both lungs. Cultures from cord blood, cardiac blood and the lungs grew beta-hemolytic Streptococcus group B. The cause of death was prolonged rupture of membranes with ascending infection, acute chorioamnionitis and foetal sepsis. This infant died from Group B Streptococcus sepsis. Prolonged rupture of membranes (>18 hours) is a significant risk factor for chorioamnionitis and neonatal sepsis. In this case, membranes had ruptured approximately 33.5 hours prior to delivery.”

yugaya

Case:2011‐S‐3
OCC File:2009‐705 The midwife dispensed an unqualified, unlicensed
“support person” to attend a woman with high risk pregnancy in an
emergency situation at 36 weeks 2 days gestation:

” In this case, the role of the support helper/attendant was to provide assistance to the registered midwife for the birth. It was not the appropriate course of action for the midwife to contact/deploy a support person who was not a registered health care provider for a patient that was G11P6 at less that 36 weeks gestation, with frank bleeding and a history of prenatal bleeding and prior retained placentae, who was in labour.

This infant was stillborn as a result of placental abruption at 36 weeks
gestation. Delays in getting to the hospital appear to be primarily a
function of the rural setting where the patient lived and possibly the weather at the time. It cannot be determined from this review whether
earlier transportation to the hospital would have resulted in a more
positive outcome.

However, upon being notified of the vaginal bleeding, and realizing the
environmental challenges of the family transporting the woman to hospital,
the midwife should have immediately contacted the local Emergency Medical Services(EMS).”

MedResident

I was listening to an analysis of this paper on CBC radio and was particularly struck by the way the outcomes were presented. The women who delivered at home were less likely to require “labor augmenting” medications, to require episiotomy, to require C/S, etc, etc … I don’t know that you can necessarily phrase those outcomes that way. Wouldn’t it be more accurate to state that these women were less likely to “receive” interventions rather than “require”? Many years into my internal medicine residency, there are definitely cases where I try to get by on alternative management plans because the location of my patient is just not amenable to the course I would ideally take. My patient in rapid afib “requires” telemetry but the hospital ward they’re on doesn’t have the equipment. So I use a portable sat probe to titrate my IV beta blockers. Technically the patient was managed without telemetry, and when I’m advocating for expanding our tele availability, I’m told “you haven’t needed it before; no one has gotten tele on this ward before”. Does this patient fall into the “does not require” column because they were also in the “did not receive”?

MaineJen

That’s like saying “The patient did not require novocaine during the Home Root Canal.” I guess now “not available” = “not needed”

sdsures

LOL

Mattie

I think you definitely can say ‘did not require’ IF the midwife attending is following the correct procedures for transfer. So, of course a woman may not need augmentation…happens in hospital too, but if she did then the midwife should transfer to hospital for that. You’d expect that the numbers of women needing augmentation would be much higher in the hospital group because 1) that’s where it happens and 2) quite a lot of women who end up needing augmentation have been risked out of the hb group.

Sue

MedResident – your approach is a standard one for a health care provider. The paper outcomes appear to be expressed in ideological terms, not scienitific ones.

We could say that women delivering in Nigeria are less likely to receive a whole gammut of interventions. That’s why they have one of the highest rates of maternal and neonatal mortality.

yugaya

2006, #21 neonatal death in “low risk” homebirth:

“This 38-year-old G2P1 sought midwifery care on Dec. 14, 2005, with an
expected due date of July 15, 2006. Her previous delivery was a 16-hour
home birth, and it appeared that the baby required some resuscitation at
delivery.

“The patient took five hours to dilate from 9 cm to 10 cm; the Society of
Obstetricians and Gynaecologists of Canada guidelines for a multiparous
woman is 1 cm per hour. The fetal heart was recorded every two to three minutes. The notes did not explain why the heart rate was being recorded so frequently. The recommendation for intermittent auscultation requires the fetal heart to be listened to ever y 15 minutes for one minute throughout active labour and the presence of periodic changes no ted. In the absence of reassuring findings, continuous electronic monitoring should be commenced. “

Trixie

So would this death have been included in this study?

yugaya

Yes, because the previous study ( 2003-2006) only counted data up to April 2006.

demodocus

” Dec. 14, 2005, with an expected due date of July 15, 2006″ This has to be a typo.

“On Aug. 25 at approximately 1030 hours, she reported ruptured membranes and contacted her midwife. Early on the morning of Aug. 26, the patient started having contractions. At that time, a brownish-green fluid was reported. The midwife assessed her at approximately 1000 hours. Since her contractions were irregular, the midwife determined that the mother was not in established labour. Membranes were confirmed as ruptured and the midwife’s notes indicate that the fluid seen at the time was clear, the cervix was 1-2 cm dilated, posterior, 25% effaced and spines -2 to -3. The midwife also noted the presence of some meconium or possibly dried blood.

The midwife arranged for an obstetrical consultation because labour had slowed down. The obstetrician saw the patient at approximately 1430 hours. The consultation report indicates that he reviewed the history and relied upon the vaginal examination as documented by the midwife.

It appears there was no clear communication between the consulting obstetrician and the midwife about the care of the patient, the issue
of monitoring and the question of in-patient versus outpatient care. As the obstetrician was consulted about the potential for intervention and the management of the pregnancy, however,it should be expected that these parameters would be dealt with both verbally and in writing.

While the cause of death was most likely hypoxemia, at autopsy there were no significant neurological changes apart from moderate congestion in both cerebral hemispheres. There was staining consistent with meconium aspiration in the terminal airways.”

The obstetrician consulted relied on midwife’s notes, and the midwife did not understand that the recommendation was for hospital. Once back in hospital it was too late and this baby was lost.

MaineJen

Wait, so the fluid was clear, but she also noted “some meconium or possible dried blood?” Or, was this a case of *wink wink* The fluid was “clear” when I checked her! *wink wink*

Trixie

Tragic

namaste863

The trouble is that NCB is less about safety and more about religious conviction. NCB is God, and Ina May Gaskin, Lisa Barett, and Laura Shanley are the prophets delivering the sacred message. Trusting birth is a matter of faith, not reason. The language of NCB dogma has all the trappings of a religious cult. We might as well try to reason with Tom Cruise that the Church of Scientology is a really clever scam to sell a lot of books and have the profits declared tax exempt (Look it up. L. Ron Hubbard and now David Miscavige was/is laughing all the way to the bank). The bad news is that in NCB land, it’s usually an innocent bystander foisted with the consequences of (erroneous) faith.

Ash

It looks like British Columbia allows midwives to deliver twins at home? And breech requires consult with OBGYN but not absolute indicator for transfer of care?

I think a Canadian MFM doc has posted about one case in which a planned OOH birth was documented as not recommended by the MWs and OBGYN but the patient insisted upon having an OOH birth. In this case, the MWs were obligated to attend. The patient was transferred to the hospital intrapartum and the MWs did a good job of transfer–they made sure they had IVs in place upon admission. I do think that some provinces in Canada allow a MW to attend a birth even if strenuously not recommended to do so, providing sufficient documentation that the patient has been counselled and still desires a OOH birth.

Haelmoon

Twins are a contraindication for home birth. We share care with the midwives, but we are in charge of obstetrical issues – fetal monitoring, ultrasounds and timing of visits. We di the deliveries together. The midwives often deliver twin A and we do twin B. If twin B is vertex, i will let the midwife deliver, but i still make sure things are going well first.
The main point of contention we have is VBACs. We do not support home VBACs, but the midwives do.

Ash

Do absolute contraindications vary by province, though?

Haelmoon

Each provincial college has their own guidelines. Individual practice group will define them further. For example, in Ontario, midwives have to support home vbac, in BC they can support it (but don’t have to). Unfortunately, they want to be very independent and some times have different recommendations than the SOGC or provincial obstetricians. The woo is creeping in up here too.

yugaya

I will post here in the comments some of the horrific and preventable deaths at the hands of Ontario Midwives that were, based on their exclusion criteria, buried twice in order to make the shiny claim how homebirth is safe. All cases are from province coroner review reports for the years 2003-2006 covered by previous study by same authors, as well as for this new one covering the period 2006 -2009. No disciplinary actions whatsoever resulted as a consequence of the actions of midwives in all of these cases according to College of Midwives of Ontario past disciplinary hearings page of their website. None.

– records missing, high risk woman in an emergency out of scope situation who was directed not to go to hospital but was instead seen by the midwife maybe in the clinic, maybe at home, no records at all:

“Because there was a previous history of placenta accreta/previa, a midwife-attended hospital birth had been planned for this birth with immediate IV setup on admission and a plan to manage the third stage of labour with oxytocin. This is not what transpired in the event. According to the midwife’s notes she recorded a gestational age of 36 weeks (37 weeks by ultrasound dating) and yet advised the mother to come to the clinic. If the gestational age were 36 weeks, this was a preterm, premature rupture of membranes with a gush – a situation requiring timely assessment.

When you add the past history of precipitate labour at 38 + weeks and
placenta accreta/previa, the location for that timely assessment should
be the hospital. Despite the midwife’s advice, there is no record of an
assessment by the midwife in her clinic or in the woman’s home. It is unclear whether the mother elected to go to hospital on her own or at the instruction of midwife”.

Amy Tuteur, MD

Is there any way to get data about the babies who died in the hospital?

yugaya

Dr Tuteur from what I can see the Chief Coroner for the Province of Ontario annual reviews of maternal and perinatal deaths contain data on all birth settings. Here are all the links for all of the relevant years ( some 2009 deaths are in the 2011 report)

It is not a complete record of losses though, just the cases where the coroner was involved. Each hospital has a quality committee that reviews all in hospital demises. In some centres, the midwives bring their cases from home birth complications to discuss with the group too.

yugaya

Those are the cases that were reviewed by provincial coroner committee in Ontario, so the already red flagged ones.

Poogles

“Women with breech, twins, medical complications of pregnancy, pre-existing medical conditions and more than one previous C-section are not eligible for homebirth in Canada.”

Am I reading this correctly – they allow HBAC so long as it was only 1 previous CS? That seems like an unnecessary risk…

Suzi Screendoor

I know someone in BC (the WOOiest province) who had an unmedicated VBAC in a hospital under the care of a midwife. I remember being surprised that she wasn’t required to be under the care of an OB.

AirPlant

As long as they are in the hospital do they really need your primary care to be provided by an OB? This could be ignorance talking, but if you are laboring literally in the hospital and there are OBs available and your midwife a real nurse midwife trained to detect catastrophy you can still get the decision to incision time needed to make things as safe as they can be.

fiftyfifty1

That is the way it worked at the hospital where I trained. CNMs could take VBACs, but an OB was always in house… closely keeping an eye on the strip.

yugaya

The strip in Ontario was ignored enough in 62 cases reviewed by Ontario coroners between 2004 and 2011 to warrant a specific recommendation to not do so in the future.

EDIT: most of the cases involved a midwife ignoring or not interpreting the strip accurately as a sign of distress.

Trixie

In the US CNMs can deliver VBACs in the hospital, too. I had to have an OB a consult and of course, the OB was there on the floor in case I needed a cesarean.

Bianca Styles

I don’t know if our midwives are any less steeped in woo than American ones. I hear a lot of “trust birth” nonsense coming from my midwife-inclined friends.
I had one friend deliver at home with a midwife here in Edmonton, Alberta. That midwife let her go nearly 3 weeks overdue, and still delivered her at home. She was a vbac too.
My friend told me this, and was proud that she got her waterbirth. All I could thing was “that midwife should not be allowed to deliver babies”.

tariqata

Is regulation of midwifery in Alberta similar to that in Ontario? The study looks like it included only births in Ontario, and at least in my limited experience, the midwife team I was with had a pretty firm policy that at 42 weeks you *must* consult with an OB and/or have an induction, for example. (I had planned a hospital birth in any case though, so I’m not as familiar with the CMO’s standards of practice for homebirth.)

Amy Tuteur, MD

Dr. Amy Tuteur is an obstetrician gynecologist. She received her undergraduate degree from Harvard College in 1979 and her medical degree from Boston University School of Medicine in 1984. Dr. Tuteur is a former clinical instructor at Harvard Medical School. She left the practice of medicine to raise her four children. Her book, Push Back: Guilt in the Age of Natural Parenting (HarperCollins) was published in 2016. She can be reached at DrAmy5 at aol dot com...
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